Post on 02-May-2023
Problem RepresentationAnd other core clinical reasoning concepts
URMC DOM Educator Development Forum November 2020
Teaching Clinical Reasoning
• Isn’t that what we do all the time?
• Encouraging the learner to reason out loud
• Prompting the learner to think in a structured fashion&
• Sharing your own thinking
• Improving care for this patient AND the next one
Suspected benefits of sound clinical reasoning
• Better diagnostic accuracy and efficiency
• Better communication with colleagues and patients
• Reduced physician anxiety (did I miss anything?)
• More professional bonding in the team• Sharing your craft, not simply correcting/evaluating the learner• Talking like a doctor
• Multiple levels of learners can participate together
• Its so much fun
Dual Process Theory
Definition Example Diagnosis
C. difficile System
1 Reflexive Acute diarrhea &recent antibiotics
colitis
System2 Analytical Chronic diarrhea Broad ddx
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Lots of patterns
• Weight gain, orthopnea and bilateral edema
• Anemia, thrombocytopenia and schistocytes
• Weight loss, dysphagia and guaiac positive stool&
• Dyspnea, hypoxia and clear CXR
The brain finds patterns everywhere • Occam's razor (diagnostic parsimony)- simplest unifying diagnosis is
preferred• Hickum’s dictum (counterargument)- the patient can have as many diseases
as they please• Crabtree’s bludgeon- “No set of mutually inconsistent observations can exist
for which some human intellect cannot conceive a coherent explanation,however complicated”
What makes good clinical reasoning
Step 1: Name the problem Problem Representation
Step 2: Work the problem Clinical schema
Step 3: Make the diagnosis (es) Illness script
Core Clinical Reasoning Vocab
• Problem Representation- the “core” of the case. The problem (s).• A short summary of the most essential/diagnostically helpful features of a case."
(e.g. A middle aged woman with acute hypoxic respiratory failure without evidenceof volume overload)
• Clinical Schema- a structured diagnostic approach to a problem.•'User specific, organized mental approach, typically patient-agnostic
• (e.g. approach to hypoxia, approach to petechial rash, approach to syncope, approach toabnormal liver enzymes)
• Illness script: A structured mental summary of a specific disease.•'User specific, grows and becomes more nuanced with experience.
• (e.g. Bacterial pneumonia in the older adult; ACS atypical presentations)
Problem Representation
• Key components
▫ Patient▫ Time course/tempo▫ Clinical syndrome (Key
signs, symptoms anddescriptors)
A 60-year-old woman with rheumatoid arthritis on prednisone presents with one day of ankle pain and swelling in thesetting of malaise, with examsignificant for tachycardia, fever, left ankle pain and swelling, and leukocytosis.
A 60 year-old immunocompromised woman with acute monoarticular arthritis and systemicinflammatory response syndrome(SIRS).
Jennifer Olenik, Jeff Kohlwes, Reza Sedighi Manesh, Denise M. Connor, JGIM ECR Team
Words Matter- clinical synthesis
DESCRIPTION SYNTHETIC CLINICAL TERM
• Right sided abdominal pain after eating • Biliary colic• Waxing and waning mental status • Delirium• Shortness of breath and hypoxia • Hypoxic respiratory failure• Cough, runny nose and fever • URI symptoms• Weight loss, falls, increasing dependency • Failure to thrive
Words Matter- use medical adjectives (Semantic qualifiers )
•'Acute • Chronic• • Localized • Diffuse"Clinically significant
descriptors •'Static • Progressive•'Single Episode • Recurrent• Often paired opposites •'Painful • Painless•'Bilious • Nonbilious•'Constant • Intermittent (eg. Colicky)•'Abrupt • Gradual•'Single • Multiple
A more muscular summary
TRADITIONAL SUMMARY PROBLEM REPRESENTATION
• Comprehensive of all potentially relevant • Selective about most helpful or highdetails priority details
• Purely objective • Intentionally selective/biased
• Purely descriptive • Partially prescriptive
• Static • Iterative
• Avoids being wrong • Hopes to be correct, but expects to bereformulated if needed
Features of diagnostic schema
• Typically organize diagnoses into a small number of conceptual“buckets” that are easy for the clinician to recall.
• Clinician-specific- The schema needs to make sense to the user&
• Help reminding us to consider less easily recalled etiologies
• Help clinician feel confident they are not “missing something”&
How can I foster this thinking)
Less helpful • What do you think is going on?
• So what’s your DDx for this patient?$
• What else could it be?
• Go read about your patients
More helpful • Lets do a problem representation!$
• What is your approach to jaundice?$
• What features are inconsistent or atypical for this diagnosis? Whatdoesn’t quite fit? • How does this case add to your
understanding of heart failure?$
Venues
• Pretty much anywhere
• Morning report • Ambulatory office • Ward rounds • Noon conference/didactics • Student preceptor rounds
Problem Representation Exercise
• For each clinical summary
• Each person should take 2 minutes and write their own ProblemRepresentation with the standard format
• Key Patient Factors (important demographics, history) • Tempo/Time Course of the problem • Clinical Syndrome (key signs/symptoms/labs)
• Goal is to create a short, high yield problem statement
• Share with your group and compare and refine